s Rare non-fatal cardiac risk should not discourage the use of adequate supervised methadone doses which save lives | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

read more
open full screen

Recent Comments

Click here to read...

News Flash

Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
Access and click on the title links that are illustrated

Comments: 1

read more
open full screen

Feature Contribution

Woolworths Pharmacy - Getting One Stage Closer

Neil Johnston

It started with “tablet” computers deployed on shelves inside the retailer Coles, specifically to provide information to consumers relating to pain management and the sale of strong analgesics.
This development was reported in i2P under the title Coles Pharmacy Expansion and the Arid PGA Landscape”
In that article we reported that qualified information was a missing link that had come out of Coles market research as the reason to why it had not succeeded in dominating the pain market.
Of course, Woolworths was working on the same problem at the same time and had come up with a better solution - real people with good information.

Comments: 5

read more
open full screen

Intensive Exposition without crossing over with a supermarket

Fiona Sartoretto Verna AIAPP

Editor's Note: The understanding of a pharmacy's presentation through the research that goes into the design of fixtures and fittings that highlight displays, is a never-ending component of pharmacy marketing.
Over the past decade, Australian pharmacy shop presentations have fallen behind in standards of excellence.
It does not take rocket science - you just have to open your eyes.
Recently, our two major supermarkets, Woolworths and Coles, have entered into the field of drug and condition information provision - right into the heartland of Australian Pharmacy.

read more
open full screen

The sure way to drive business away

Gerald Quigley

I attended the Pregnancy, Baby and Children’s Expo in Brisbane recently.
What an eye and ear opening event that was!
Young Mums, mature Mums, partners of all ages, grandparents and friends……...many asking about health issues and seeking reassurances that they were doing the right thing.

Comments: 1

read more
open full screen

‘Marketing Based Medicine’ – how bad is it?

Baz Bardoe

It should be the scandal of the century.
It potentially affects the health of almost everyone.
Healthcare providers and consumers alike should be up in arms. But apart from coverage in a few credible news sources the problem of ‘Marketing Based Medicine,’ as psychiatrist Dr Peter Parry terms it, hasn’t as yet generated the kind of universal outrage one might expect.

read more
open full screen

Community Pharmacy Research - Are You Involved?

Mark Coleman

Government funding is always scarce and restricted.
If you are ever going to be a recipient of government funds you will need to fortify any application with evidence.
From a government perspective, this minimises risk.
I must admit that while I see evidence of research projects being managed by the PGA, I rarely see community pharmacists individually and actively engaged in the type of research that would further their own aims and objectives (and survival).

read more
open full screen

Organisational Amnesia and the Lack of a Curator Inhibits Cultural Progress

Neil Johnston

Most of us leave a tremendous impact on pharmacies we work for (as proprietors, managers, contractors or employees)—in ways we’re not even aware of.
But organisational memories are often all too short, and without a central way to record that impact and capture the knowledge and individual contributions, they become lost to time.
It is ironic that technology has provided us with phenomenal tools for communication and connection, but much of it has also sped up our work lives and made knowledge and memory at work much more ephemeral.

read more
open full screen

Academics on the payroll: the advertising you don't see

Staff Writer

This article was first published in The Conversation and was written by Wendy Lipworth, University of Sydney and Ian Kerridge, University of Sydney
In the endless drive to get people’s attention, advertising is going ‘native’, creeping in to places formerly reserved for editorial content. In this Native Advertising series we find out what it looks like, if readers can tell the difference, and more importantly, whether they care.
i2P has republished the article as it supports our own independent and ongoing investigations on how drug companies are involved in marketing-based medicine rather than evidence-based medicine.

read more
open full screen

I’ve been thinking about admitting wrong.

Mark Neuenschwander

Editor's Note: This is an early article by Mark Neuenschwander we have republished after the soul-searching surrounding a recent Australian dispensing error involving methotrexate.
Hmm. There’s more than one way you could take that, huh? Like Someday when I get around to it (I’m not sure) I may admit that I was wrong about something. Actually, I’ve been thinking about the concept of admitting wrong. So don’t get your hopes up. No juicy confessions this month except that I wish it were easier for me to admit when I have been wrong or made a mistake.
Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

read more
open full screen

Dispensing errors – a ripple effect of damage

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Most readers will be aware of recent publicity relating to dispensing errors and in particular to deaths caused by methotrexate being incorrectly packed in dose administration aids.
The Pharmacy Board of Australia (PBA), in its Communique of 13 June 2014, described a methotrexate packing error leading to the death of a patient and noted “extra vigilance is required to be exercised by pharmacists with these drugs”.
This same case was reported by A Current Affair (ACA) in its program on Friday 20 June
http://aca.ninemsn.com.au/article/8863098/prescription-drug-warning

read more
open full screen

Take a vacation from your vocation

Harvey Mackay

Have you ever had one of those days when all you could think was, “Gosh, do I need a vacation.”
Of course you have – because all work and no play aren’t good for anyone.
A vacation doesn’t have to be two weeks on a tropical island, or even a long weekend at the beach. 
A vacation just means taking a break from your everyday activities. 
A change of pace. 
It doesn’t matter where.
Everyone needs a vacation to rejuvenate mentally and physically. 
But did you also know that you can help boost our economy by taking some days off? 
Call it your personal stimulus package.

read more
open full screen

Explainer: what is peer review?

Staff Writer

This article was first published in the Conversation. It caught our eye because "peer review" it is one of the standards for evidence-based medicines that has also been corrupted by global pharma.
The article is republished by i2P as part of its ongoing investigation into scientific fraud and was writtenby Andre Spicer, City University London and Thomas Roulet, University of Oxford
We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean?
How does it work?
Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists' work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.
Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators.
The intention behind this system is to ensure evaluation is not biased.
The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

read more
open full screen

Dentists from the dark side?

Loretta Marron OAM BSc

While dining out with an elderly friend, I noticed that he kept his false tooth plate in his shirt pocket. He had recently had seven amalgam-filled teeth removed, because he believed that their toxins were making him sick; but his new plate was uncomfortable. He had been treated by an 'holistic dentist'. Claiming to offer a "safe and healthier alternative" to conventional dentistry, are they committed to our overall health and wellbeing or are they promoting unjustified fear, unnecessarily extracting teeth and wasting our money?

read more
open full screen

Planning for Profit in 2015 – Your key to Business Success

Chris Foster

We are now entering a new financial year and it’s a great time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.
It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.
The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

read more
open full screen

ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

read more
open full screen

Attracting and Retaining Great People

Barry Urquhart

Welcome to the new financial year in Australia.
For many in business the past year has been described as a challenging period.
Adjectives are a key feature of the English language.  In the business lexicon their use can be, and often is evocative and stimulate creative images.  But they can also contribute to inexact, emotional perceptions.
Throughout the financial pages of newspapers and business magazines adjectives abound.
References to “hot” money draw attention and comment.  The recent wave of funds from Chinese investors, keen to remove their wealth from the jurisdiction and control of government regulations is creating a potential property bubble in Australia.

read more
open full screen

Updating Your Values - Extending Your Culture

Neil Johnston

Pharmacy culture is dormant.
Being comprised of values, unless each value is continually addressed, updated or deleted, entire organisations can stagnate (or entire professions such as the pharmacy profession).
Good values offer a strong sense of security, knowing that if you operate within the boundaries of your values, you will succeed in your endeavours.

read more
open full screen

Evidence-based medicine is broken. Why we need data and technology to fix it

Staff Writer

The following article is reprinted from The Conversation and forms up part of our library collection on evidence-based medicines.
At i2P we also believe that the current model of evidence is so fractured it will never be able to be repaired.
All that can happen is that health professionals should independently test and verify through their own investigations what evidence exists to prescribe a medicine of any potency.
Health professionals that have patients (such as pharmacists) are ideally placed to observe and record the efficacy for medicines.
All else should confine their criticisms to their evidence of the actual evidence published.
If there are holes in it then share that evidence with the rest of the world.
Otherwise, do not be in such a hurry to criticise professions that have good experience and judgement to make a good choice on behalf of their patients, simply because good evidence has not caught up with reality.

read more
open full screen

Laropiprant is the Bad One; Niacin is/was/will always be the Good One

Staff Writer

Orthomolecular Medicine News Service, July 25, 2014
Laropiprant is the Bad One; Niacin is/was/will always be the Good One
by W. Todd Penberthy, PhD

(OMNS July 25, 2014) Niacin has been used for over 60 years in tens of thousands of patients with tremendously favorable therapeutic benefit (Carlson 2005).
In the first-person NY Times best seller, "8 Weeks to a Cure for Cholesterol," the author describes his journey from being a walking heart attack time bomb to a becoming a healthy individual.
He hails high-dose niacin as the one treatment that did more to correct his poor lipid profile than any other (Kowalski 2001).

read more
open full screen

Culture Drive & Pharmacy Renewal

Neil Johnston

Deep within all of us we have a core set of values and beliefs that create the standards of behaviour that we align with when we set a particular direction in life.
Directions may change many times over a lifetime, but with life experiences and maturity values may increase in number or gain greater depth.
All of this is embraced under one word – “culture”.
When a business is born it will only develop if it has a sound culture, and the values that comprise that culture are initially inherent in the business founder.
A sound business culture equates to a successful business and that success is often expressed in the term “goodwill” which can be eventually translated to a dollar value.

read more
open full screen

ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

read more
open full screen

Pharmacy 2014 - Pharmacy Management Conference

Neil Johnston

The brave new world of health and wellness is not the enemy of Pharmacy, it is its champion.
Australian futurist, Morris Miselowski, one of the world's leading business visionaries, will present the Opening Keynote address on Pharmacy's Future in the new Health and Wellness Landscape at 2.00pm on Wednesday July 30.
Morris believes the key to better health care could already be in your pocket, with doctors soon set to prescribe iPhone apps, instead of pills.
Technology will revolutionise the health industry - a paradigm shift from healthcare to personal wellness.
Health and wellness applications on smartphones are already big news, and are dramatically changing the way we manage our personal health and everyday wellness.

read more
open full screen

Generation and Application of Community Pharmacy Research

Neil Johnston

Editor’s Note: We have had a number of articles in this issue relating to pharmacy research.
The PGA has conducted a number of research initiatives over the years, including one recently reported in Pharmacy News that resulted from an analysis of the QCPP Patient Questionnaire.
Pharmacy Guild president, George Tambassis, appears to have authored the article following, and there also appears to be a disconnect between the survey report and its target audience illustrated by one of the respondent comments published.
I have asked Mark Coleman to follow through, elaborate and comment:

read more
open full screen

Rare non-fatal cardiac risk should not discourage the use of adequate supervised methadone doses which save lives

Dr Andrew Byrne & Associates

articles by this author...

A Harm-Minimisation Research Perspective: Dr Byrne (and his associates) advocate for better policies which are proven to reduce risks for drug users and the general community, under a framework in parallel with Australia’s official policy of harm minimisation.

Roy A, McCarthy C, Kiernan G, McGorrian C, Keenan E, Mahon N, Sweeney B. Increased incidence of QT interval prolongation in a population receiving lower doses of methadone maintenance therapy. Addiction 2012 107;6:1132-9

Dear Readers,

These Irish researchers examine QT intervals in relation to methadone dose, cocaine, opiates and benzodiazepine use in 180 stable maintenance patients (total clinic population 376). 
They find that 9-11% have ‘drug induced’ QT prolongation despite finding no relation to daily methadone dose (which was a healthy mean of 80mg, SD 27mg) and no control group. 
Nor was there any relation between QT interval and the presence of cocaine in toxicology tests.

open this article full screen

The article’s title makes an implication about the relevance of high versus low dose methadone in relation to QT prolongation.  Yet the very first report of nine dependency cases had six taking less than 130mg daily and four taking less than 100mg (ref 1 - but see below why this cannot be gleaned from the paper directly). 

 

QT prolongation has been reported in a high proportion of potential methadone recipients, but who were not actually taking methadone at the time.  In hospice patients being considered for methadone treatment Reddy found QT prolongation in 28%.  Lipski and her colleagues in 1973 reported 19% of street heroin users had QT prolongation before starting methadone treatment. 

 

It is clear that a population of patients taking a variety of medications and with certain underlying illnesses such as HIV and hepatitis C are at risk of having QT prolongation, quite apart from any methadone treatment.  Alcohol is also believed to be a risk factor [ref 4].  With a lack of any reported cases of this arrhythmia in 37 years, one might reasonably infer that this issue was not a major clinical problem in methadone prescribed patients. 

 

Yet in the past decade there have been just over 100 reported cases of torsade in methadone patients.  So, as our patients have survived their addiction, viral infections (and especially treatment for those infections), a small proportion have reached an age at which they have become susceptible to a rare clinical entity which most large centres have now seen at least once.  Torsade de pointes was so rare amongst methadone recipients in 2002 that it was thought to be a new entity [see ref 13 for an earlier report].  Yet torsade de pointes was delineated and re-branded in the 1960s by a French group (no relation to methadone which was not used in that country at the time) [ref 11].  In 1985 another French group also provided a systematic approach to torsade treatment such that for eight years they had a mortality of zero [ref 12]. 

 

One may ask why we do not see more torsade de pointes since QT prolongation has a high prevalence in out treatment population.  In a RCT Wedam [ref 8] found ~10% of new methadone recipients in Baltimore had QTc > 500mg (but no torsade cases), yet contrary-wise nearly all of the reports of torsade are in longer-term patients [ref 5 and pers comm]. 

 

So QT prolongation, even at the level of greater than 500ms in this population of methadone recipients does not appear to confer a measurable risk of torsade de pointes tachycardia (and numerous torsade cases had normal ECG away from the arrhythmia episode). 

 

While torsade is symptomatically a distressing and unpleasant condition, it is rarely if ever fatal and is “controllable 100% of the time” with modern treatment, according to US cardiologist Phibbs [ref 6]. 

 

Suggestions from some quarters that there may be large numbers of unrecognised deaths due to torsade are not credible for two reasons: (1) deaths of patients on methadone programs are reportedly very rare and (2) such deaths are usually rigorously investigated by coroners and positive findings are the rule with only very occasional ‘unknown causes’ which might include a fatal arrhythmia [Anchesen; Perrin-Terrin, refs 9 and 10]. 

 

It is regrettable that in his seminal article on the subject Krantz did not delineate pain from addiction subjects [1].  This appears to have caused a decade of confusion about the supposed effect of extremely high doses of methadone (see Annals Editorial comments relating to “very-high-dose methadone”).  When the cases were separated for the reader in a follow-up paper [7], it became clear that torsade may occur in those taking average doses as well as with the supra-therapeutic doses cited by Krantz’s group (up to 1000mg daily in the pain cases).  Yet only two of nine addiction cases were taking such doses when developing torsade de pointes.  Six of the nine were prescribed between 65mg and 125mg (mean 96mg), which are dose levels found commonly in methadone maintenance treatment reports.  There were no deaths among these nine MMT patients.  Indeed there are no documented torsade deaths in MMT as far as I can find in the entire literature (one suspected death in France has been reported). 

 

Krantz’s finding of nine cases of torsade in a small catchment over a relatively short period remains to be explained as it has never been duplicated anywhere else in the world to my best knowledge.  Most reports have been of one or two cases.  One wonders if there were other factors at play such as a viral induced cluster, the high altitude in Denver or some other factor unique to Krantz’s area.  

 

It is often instructive to go back to the original sources and while most cite Lipski et al., few seem to have actually read the paper which is elegantly written.  Even some major authors on the subject apparently believed that Lipski and colleagues were examining the effect of methadone on the QT interval.  They were in fact examining why so many heroin users in New York died of apparent overdose but with relatively low levels of morphine at post-mortem examination, proposing arrhythmia in some such cases (from heroin or other street drugs).  As they had no way of testing QT effects from heroin, ECG changes were examined in new entrants to treatment at their methadone program (which closed down recently, to the shame of the otherwise venerable Mt Sinai Medical Center in northern Manhattan). 

 

In short, these early researchers performed 12-lead cardiographs on 75 patients new to methadone treatment.  About half had not yet started treatment and had used heroin in the previous 24 hours.  The rest were already taking methadone and a range of other drugs as shown by urine testing.  The first group had prolonged QT intervals in 19% of subjects while the new patients who had started treatment had a rate of 34%.  The latter were reportedly using combinations of heroin, cocaine, methadone and other drugs.  So their theory was not confirmed yet their findings indicated a possibility that methadone extended the QT interval despite this being asymptomatic in all cases.  Further, there were no reports of arrhythmias in MMT patients for the next 29 years. 

 

This leaves us asking why one would spend time and money highlighting, emphasising and investigating the torsade issue while ignoring the vastly more important issue of standards of treatment.  Drop-outs, deaths, overdose, viral infection, unemployment, etc, are all well documented consequences of deficient doses, inadequate supervision and a lack of psychosocial supports which are still sadly common.  Each of these factors was clearly delineated in Dole’s first report in 1965 - and which modern prescribers ignore to their patients’ eternal cost. 

 

Notes by Andrew Byrne .. Clinic web page: http://methadone-research.blogspot.com/   

 

 

REFERENCES:

1. Krantz MJ, Lewkowiez L, Hays H, Woodroffe MA, D. Robertson AD, Mehler PS. Torsade de Pointes Associated with Very-High-Dose Methadone. Ann Intern Med. 2002 137:501-504

 

2. Reddy S, Fisch M, Bruera E. Oral methadone for cancer pain: no indication of Q-T interval prolongation or torsades de pointes.  Journal of Pain and Symptom Management 2004 28;4:301-303

 

3. Lipski J, Stimmel B, Donoso E. The effect of heroin and multiple drug abuse on the electrocardiogram. American Heart J 1973 86:663-8

 

4. Hyslop B. Prolongation of the QT interval on methadone: how important is methadone dose? New Zealand Medical Student Journal 2007 6 Aug

 

5. Justo D, Gal-Oz A, Paran Y, Goldin Y, Zeltser D. Methadone-associated Torsades de Pointes (polymorphic ventricular tachycardia) in opioid-dependent patients. Addiction. 2006 101:1333-1338

 

6. Phibbs B. Advanced ECG: boards and beyond. 2006 Elsevier

 

7. Krantz MJ, Kutinsky IB, Robertson AD, Mehler PS. Dose-related effects of methadone on QT prolongation in a series of patients with torsade de pointes. Pharmacotherapy. 2003;23:802-805

 

8. Wedam EF, Bigelow GE, Johnson RE, Nuzzo PA, Haigney MCP. QT-Interval Effects of Methadone, Levomethadyl, and Buprenorphine in a Randomized Trial. Arch Intern Med 2007 167;22:2469-2473

 

9. Anchersen K, Clausen T, Gossop M, Hansteen V, Waal H. Prevalence and clinical relevance of QTc interval prolongation during methadone and buprenorphine treatment: a mortality assessment study. Addiction 2009 104;6:993-999

 

10. Perrin-Terrin A, Pathak A, Lapeyre-Mestre M. QT interval prolongation: prevalence, risk factors and pharmacovigilance data among methadone-treated patients in France. Fundam Clin Pharmacol. 2010 Sep 6

 

11. Dessertenne PF. La tachycardie ventriculaire a deux foyers opposes variables. Arch Mal Coeur 1966 59:263-72

 

12. Salle P, Rey JL, Bernasconi P, et al. Torsades de pointe. Apropos of 60 cases. Ann Cardiol Angeiol (Paris). Jun 1985;34(6):381-8

 

13. Bittar P, Piguet V, Kondo-Oestreicher J et al. Methadone induced long QTc and "torsade de pointe". Swiss Medical Forum 2002 S4;P244:36S

Return to home

Post new comment

The content of this field is kept private and will not be shown publicly.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Allowed HTML tags: <a> <em> <strong> <cite> <code> <ul> <ol> <li> <dl> <dt> <dd>
  • Lines and paragraphs break automatically.

More information about formatting options

CAPTCHA
This question is for testing whether you are a genuine visitor, to prevent automated spam submissions.
Incorrect please try again
Enter the words above: Enter the numbers you hear:

health news headlines provided courtesy of Medical News Today.

Click here to read more...

If any difficulty is found in subscribing, please use the "Contact Us" panel found in the navigation bar with the message "subscribe" and your email address.

Subscribe to our mailing list

Email Format
 

 

  • Copyright (C) 2000-2019 Computachem Services, All Rights Reserved.

Website by Ablecode